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To test the hypothesis that long-term care facility (LTCF) residents with Clostridium difficile infection (CDI) or asymptomatic carriage of toxigenic strains are an important source of transmission in the LTCF and in the hospital during acute-care admissions.

Design

A 6-month cohort study with identification of transmission events was conducted based on tracking of patient movement combined with restriction endonuclease analysis (REA) and whole-genome sequencing (WGS).

Setting

Veterans Affairs hospital and affiliated LTCF.

Participants

The study included 29 LTCF residents identified as asymptomatic carriers of toxigenic C. difficile based on every other week perirectal screening and 37 healthcare facility-associated CDI cases (ie, diagnosis >3 days after admission or within 4 weeks of discharge to the community), including 26 hospital-associated and 11 LTCF-associated cases.

Results

Of the 37 CDI cases, 7 (18·9%) were linked to LTCF residents with LTCF-associated CDI or asymptomatic carriage, including 3 of 26 hospital-associated CDI cases (11·5%) and 4 of 11 LTCF-associated cases (36·4%). Of the 7 transmissions linked to LTCF residents, 5 (71·4%) were linked to asymptomatic carriers versus 2 (28·6%) to CDI cases, and all involved transmission of epidemic BI/NAP1/027 strains. No incident hospital-associated CDI cases were linked to other hospital-associated CDI cases.

Conclusions

Our findings suggest that LTCF residents with asymptomatic carriage of C. difficile or CDI contribute to transmission both in the LTCF and in the affiliated hospital during acute-care admissions. Greater emphasis on infection control measures and antimicrobial stewardship in LTCFs is needed, and these efforts should focus on LTCF residents during hospital admissions.

We conducted a non-blinded randomized trial to determine the impact of a patient hand-hygiene intervention on contamination of hospitalized patients’ hands with healthcare-associated pathogens. Among patients with negative hand cultures on admission, recovery of pathogens from hands was significantly reduced in those receiving the intervention versus those receiving standard care.

In an experimental study, the frequency of contamination of healthcare personnel during removal of contaminated personal protective equipment (PPE) was similar for bacteriophage MS2 and a novel reflective marker visualized using flash photography. The reflective marker could be a useful tool to visualize and document personnel contamination during PPE removal.

In an observational study, we found that healthcare personnel frequently acquired Clostridium difficile on their hands when caring for patients with recently resolved C. difficile infection (CDI) (<6 weeks after treatment) who were no longer under contact precautions. Continuing contact precautions after diarrhea resolves may be useful to reduce transmission.

Of 134 patients diagnosed with Clostridium difficile infection, 30 (22%) did not meet clinical criteria for testing because they lacked significant diarrhea or had alternative explanations for diarrhea and no recent antibiotic exposure. For these patients, skin and/or environmental contamination was common only in those with prior antibiotic exposure.

We used a colorimetric assay to determine the presence of chlorhexidine on skin, and we identified deficiencies in preoperative bathing and daily bathing in the intensive care unit. Both types of bathing improved with an intervention that included feedback to nursing staff. The assay provides a simple and rapid method of monitoring the performance of chlorhexidine bathing.

We found that a majority of hospitalized patients were aware of the importance of hand hygiene, but observations indicated that performance of hand hygiene was uncommon. An intervention in which healthcare personnel facilitated hand hygiene at specific moments significantly increased performance of hand hygiene by patients.

Of 82 patients with methicillin-resistant Staphylococcus aureus (MRSA) colonization, 67 (82%) had positive hand cultures for MRSA. A single application of alcohol gel (2 mL) consistently reduced the burden of MRSA on hands. However, incomplete removal of MRSA was common, particularly in those with a high baseline level of recovery.

Recurrent skin and soft-tissue infections (SSTIs) due to Staphylococcus aureus are a common problem in children and adults. Many of these SSTIs are caused by a community-associated methicillin-resistant S. aureus (MRSA) strain designated USA300. Dilute bleach baths are commonly used as part of decolonization regimens for recurrent SSTI, particularly in children. However, limited data are available on the microbiological efficacy of dilute bleach on skin, and optimal concentrations are unknown. Recent practice guidelines for MRSA from the Infectious Diseases Society of America recommend a teaspoon of household bleach per gallon of bath water (1.3 μL/mL or a quarter cup per quarter tub of water) for 15 minutes twice weekly. On the basis of in vitro data, Fisher et al suggested that a higher concentration (2.5 μL/mL or a half cup per quarter tub of water) might be more effective (more than a 3-log reduction in MRSA in 5 minutes versus a 2-log reduction for a 1.2-μL/mL concentration). In contrast, more dilute bleach solutions (eg, a quarter cup of 6% sodium hypochlorite per bathtub full of water) for 5 days in combination with intranasal mupirocin were effective for eradication of colonization in a recent randomized trial, but 29% of patients in the mupirocin/bleach bath group developed recurrent colonization within 4 months. Here, we used a pig skin model to examine the effectiveness of various concentrations of dilute bleach solution and an electrochemically activated saline solution containing 0.025% hypochlorous acid (Vashe; PuriCore) for disinfection of MRSA on skin. Vashe is safe for use on skin and is commercially available as a wound care product.

Effective disinfection of hospital rooms after discharge of patients with Clostridium difficile infection (CDI) is necessary to prevent transmission. Unfortunately, several studies have demonstrated that it is not uncommon for environmental cultures to remain positive for C. difficile after cleaning and disinfection of rooms in which a patient with CDI has been hospitalized (CDI rooms) by environmental services personnel. Cultures for C. difficile could potentially be useful to monitor disinfection of CDI rooms, but they are neither widely available nor efficient. There is a need for easy-to use and rapid methods to assess the effectiveness of CDI room disinfection. Adenosine triphosphate (ATP) bioluminescence assays provide a rapid assessment of cleaning effectiveness, because detection of ATP on surfaces indicates the presence of residual organic material (eg, bacteria, human secretions or excretions, and food). Detection of ATP is commonly used in the food and beverage industry and is increasingly being used in health care facilities to assess the adequacy of cleaning procedures. It is not known whether measurement of ATP on surfaces is useful to evaluate disinfection of CDI rooms. Here, we tested the hypothesis that low ATP readings on cleaned surfaces in CDI rooms would be predictive of negative cultures for C. difficile.

In a prospective study of inpatients tested for Clostridium difficile infection (CDI), skin and environmental contamination were common at the time of the order for CDI testing, and there were often delays in completion of testing. Preemptive isolation of patients with suspected CDI may reduce the risk of transmission.

In a randomized nonblinded trial, we demonstrated that daily disinfection of high-touch surfaces in rooms of patients with Clostridium difficile infection and methicillin-resistant Staphylococcus aureus colonization reduced acquisition of the pathogens on hands after contacting high-touch surfaces and reduced contamination of hands of healthcare workers caring for the patients.

Infect Control Hosp Epidemiol 2012;33(10):1039-1042

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